Mechanical failure due to dislocation, fracture and acetabular wear as well as persistence of infection are the main complications associated with the use of hip spacers in the treatment of periprosthetic joint infections (PJI).

We have developed a novel, custom-made spacer as part of two-stage septic hip replacement and present the two- to five-year results after reimplantation.

We prospectively examined a total of 73 patients over our study period in whom our new spacer technique was used. The technique includes a dual mobility inlay and a cemented straight stem in combination with antibiotic-loaded PMMA bone cement which allows full weight bearing meanwhile the interim period. The follow-up ranged between 24 and 60 months after reimplantation as second stage of a two-stage approach. The patients were contacted as part of the follow-up using a questionnaire concerning reoperation, reinfection as well as hip function by using the Harris Hip Score.

72 patients (98,6%) could be reimplanted, one patient is still using the spacer prothesis for 45 months because of excellent functional results with a Harris Hip Score of 95, nevertheless reimplantation is planned. The reinfection rate was less than 7% after reimplantation. The dislocation rate was 5%, and in total there was an overall complication rate of less than 10%. The Harris Hip Score was significantly improved.

The ENDO spacer surgical technique is a promising option in the treatment of periprosthetic joint infections (PJI) for two-stage septic exchange with a low dislocation rate and good infection control after reimplantation. In addition, it enables early mobilization with the possibility of full weight-bearing in the interval between spacer implantation and reimplantation.

Aims

One-stage exchange for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is gaining popularity. The outcome for a repeat one-stage revision THA after a failed one-stage exchange for infection remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat one-stage exchange, and to investigate the association between the Musculoskeletal Infection Society (MSIS) staging system and further infection-related failure.

Aims

One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions.

Arthrofibrosis is a relatively frequent complication after total knee arthroplasty. Although stiffness after total hip arthroplasty (THA), because of formation of heterotopic ossification or other causes, is not uncommon, to the authors’ best knowledge, arthrofibrosis after THA has not been described. The aim of this study is to describe the arthrofibrosis of the hip after primary total hip arthroplasty using an established clinical and histological classification of arthrofibrosis.

We retrospectively examined all patients who were histologically confirmed to have arthrofibrosis after primary THA during revision surgery by examination of tissue samples in our clinic. Arthrofibrosis was diagnosed according to the histopathological SLIM-consensus classification, which defines seven different SLIM types of the periimplant synovial membrane. The SLIM type V determines the diagnosis of endoprosthesis-associated arthrofibrosis.

The study population consists of 66 patients who were revised due to arthrofibrosis after primary THA. All patients had a limitation in range of motion prior to revision with a mean flexion of 90° (range from 40 to 125), mean internal rotation of 10° (range from 0 to 40) and mean external rotation of 20° (range from 0 to 50). All patients had histological SLIM type V arthrofibrosis, corresponding to endoprosthesis-associated arthrofibrosis. Histological examination revealed that seven patients (10.6%) had particle-induced and 59 patients (89.4%) had non-particle-induced arthrofibrosis.

This is the first decription of endoprosthetic-associated arthrofibrosis after primary THA on the basis of a well-established histological classification. Our study results could enable new therapeutic and diagnostic opportunities in patients with such an arthrofibrosis. Surgeons should keep arthrofibrosis as a possible cause for stiffness and pain after primary total hip arthroplasty in mind. Level of evidence Diagnostic study, Level of Evidence IV

Thorsten Gehrke and Lara Althaus contributed equally to the writing of this manuscript.

The presence of obesity has negative influence on the progress of osteoarthritis and increases the risk of undergoing a primary THA at an earlier age. However, the correlation of BMI and the risk for postoperative complications, revision surgery and infection rate is still controversial. In the largest cohort to this date, we used the German insurance claims database to evaluate the correlation of BMI and the risk of postoperative complications, mortality and revision rates following primary THA.

Using nationwide billing data of the German health-care insurance for inpatient hospital treatment, we identified patients over the age of 20 years who had undergone either THA or short-stem THA between January 2012 and December 2014. BMI was classified into four groups (< 30 kg/m², 30 to 34.9 kg/m², 35 to 39.9 kg/m², > 40 kg/m²). In all patients, the 90-day complication, mortality and revision rates were calculated. Furthermore, all complications and revisions were determined at a latest follow-up of 1 year. We used multivariable logistic regression to model the odds of complications as a function of BMI groups. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated.

A total of 131,576 total hip arthroplasties in 124,368 patients were included for final analysis. BMI had a significant effect on risk adjusted 1-year overall complications, 1-year revision surgery and 90-day surgical complications. The adjusted odd ratios increased significantly with BMI category. Especially morbidly obese patients with a BMI >40 kg/m² had a threefold higher risk for deep infection and a two-fold higher risk for the overall complication and revision rates as compared to patients with a BMI <30 kg/m².

Obesity plays an important role in patients undergoing primary THA, especially patients with a BMI beyond 40 kg/m² have a markedly higher risk for revision surgery and overall complication rates. This study aims to increase awareness among physicians in order to improve risk stratifications and to better educate patients with regard to obesity and postoperative expectations prior to undergoing elective total hip arthroplasty.

The World Health Organization (WHO) and the Centre for Disease Control and Prevention (CDC) recently published guidelines for the prevention of surgical site infection. The WHO guidelines, if implemented worldwide, could have an immense impact on our practices and those of the CDC have implications for healthcare policy in the United States.

Our aim was to review the strategies for prevention of periprosthetic joint infection in light of these and other recent guidelines.

Cite this article: Bone Joint J 2017;99-B(4 Supple B):3–10.

The aim of this study was to assess the role of synovial C-reactive protein (CRP) in the diagnosis of chronic periprosthetic hip infection. We prospectively collected synovial fluid from 89 patients undergoing revision hip arthroplasty and measured synovial CRP, serum CRP, erythrocyte sedimentation rate (ESR), synovial white blood cell (WBC) count and synovial percentages of polymorphonuclear neutrophils (PMN). Patients were classified as septic or aseptic by means of clinical, microbiological, serum and synovial fluid findings. The high viscosity of the synovial fluid precluded the analyses in nine patients permitting the results in 80 patients to be studied. There was a significant difference in synovial CRP levels between the septic (n = 21) and the aseptic (n = 59) cohort. According to the receiver operating characteristic curve, a synovial CRP threshold of 2.5 mg/l had a sensitivity of 95.5% and specificity of 93.3%. The area under the curve was 0.96. Compared with serum CRP and ESR, synovial CRP showed a high diagnostic value. According to these preliminary results, synovial CRP may be a useful parameter in diagnosing chronic periprosthetic hip infection.

Cite this article: Bone Joint J 2015; 97-B:173–6.

Louis Pasteur once said that: “Fortune favours the prepared mind.” As one of the great scientists who contributed to the fight against infection, he emphasised the importance of being prepared at all times to recognise infection and deal with it. Despite the many scientific discoveries and technological advances, such as the advent of antibiotics and the use of sterile techniques, infection continues to be a problem that haunts orthopaedic surgeons and inflicts suffering on patients.

The medical community has implemented many practices with the intention of preventing infection and treating it effectively when it occurs. Although high-level evidence may support some of these practices, many are based on little to no scientific foundation. Thus, around the world, there is great variation in practices for the prevention and management of periprosthetic joint infection.

This paper summaries the instigation, conduct and findings of a recent International Consensus Meeting on Surgical Site and Periprosthetic Joint Infection.

Cite this article: Bone Joint J 2013;95-B:1450–2.

Femoral revision after cemented total hip replacement (THR) might include technical difficulties, following essential cement removal, which might lead to further loss of bone and consequently inadequate fixation of the subsequent revision stem.

Femoral impaction allografting has been widely used in revision surgery for the acetabulum, and subsequently for the femur. In combination with a primary cemented stem, impaction grafting allows for femoral bone restoration through incorporation and remodelling of the impacted morsellized bone graft by the host skeleton. Cavitary bone defects affecting meta-physis and diaphysis leading to a wide femoral shaft, are ideal indications for this technique. Cancellous allograft bone chips of 1 mm to 2 mm size are used, and tapered into the canal with rods of increasing diameters. To impact the bone chips into the femoral canal a prosthesis dummy of the same dimensions of the definitive cemented stem is driven into the femur to ensure that the chips are very firmly impacted. Finally, a standard stem is cemented into the neo-medullary canal using bone cement.

To date several studies have shown favourable results with this technique, with some excellent long-term results reported in independent clinical centres worldwide.

Cite this article: Bone Joint J 2013;95-B, Supple A:92–4.

Based on the first implementation of mixing antibiotics into bone cement in the 1970s, the Endo-Klinik has used one stage exchange for prosthetic joint infection (PJI) in over 85% of cases. Looking carefully at current literature and guidelines for PJI treatment, there is no clear evidence that a two stage procedure has a higher success rate than a one-stage approach. A cemented one-stage exchange potentially offers certain advantages, mainly based on the need for only one operative procedure, reduced antibiotics and hospitalisation time. In order to fulfill a one-stage approach, there are obligatory pre-, peri- and post-operative details that need to be meticulously respected, and are described in detail. Essential pre-operative diagnostic testing is based on the joint aspiration with an exact identification of any bacteria. The presence of a positive bacterial culture and respective antibiogram are essential, to specify the antibiotics to be loaded to the bone cement, which allows a high local antibiotic elution directly at the surgical side. A specific antibiotic treatment plan is generated by a microbiologist. The surgical success relies on the complete removal of all pre-existing hardware, including cement and restrictors and an aggressive and complete debridement of any infected soft tissues and bone material. Post-operative systemic antibiotic administration is usually completed after only ten to 14 days.

Cite this article: Bone Joint J 2013;95-B, Supple A:77–83.